Retained Placenta

Anger (pronounced Ang-eer) was here a few months back. I remember her well because she delivered prematurely at 5 months.                      --That’s not something one forgets quickly.

At the time it came as a shock to me how she could be 5 months pregnant without a fundal height of any kind. Her whole history and situation was a puzzle.         --It still is.

Afterward I treated her for STD’s and cautioned her to come regularly for prenatal check-ups if she conceived again.

Well she did conceive. And she did come.

This time we found fetal heart tones early in her second trimester and her belly was growing nicely. Both hopeful things would go better, we prayed expectantly.

But once again at 5 months gestation, she started bleeding.

When she arrived and I flipped through her book my heart stopped as flashbacks of her last stillbirth played through my brain.

Were we doomed to repeat it again?

Sure enough upon examination she was delivering prematurely. Her curled fetus came out with little difficulty, but the placenta was another matter.

Long story short, I was not able to get it out.

We tried drugs and procedures but they failed. We waited and prayed... but the little bugger wouldn’t come.

I was even ready to try and vacuum it out with our manual vacuum aspirator (MVA) but it broke in my hands.         --Sigh.

And I ended up sending her to Wau for a D&C.

Please pray with me that we’d be able to learn what is causing her repeat stillbirths. Pray that her husband and his other wife -- and Anger -- would all come for more STDs treatments.

Thanks.

Helpless.

Last night just as I prepared to put the cap on the end of a good day (happy prenatals, beautiful breech birth, etc.) in walked a labor, then another... and then two others followed.

What? Four labors all at the same time?

The first to come in was a G2 in early labor. She lived close by and opted to go home and labor until she became active. I told Sarah that she should catch this one (since it should be simple) and I’d supervise. The woman’s name was Victoria.

Then Adeng showed up. Adeng was a G1 (first time mom) who had been here earlier in the day for a prenatal. I had diagnosed her with STDs and warned her not to go into labor until the medicines were finished. She nodded in comprehension, forgetting that women don’t get to choose when they start labor. However, once she got home, the contractions started.

Now, she was back on my prenatal bed --in labor with STDs.

As I counted contractions, there was no denying the fact that labor was on its way. The progress was slow and steady, but she was good about moving around. Her family watched her like a hawk, hovering around her as she walked. This was her first, so the pressure to have her get the childbirth confession was strong; they wanted to be in the room all the time.

Then Aboul showed up.

She announced her arrival by throwing herself on the clinic porch with melodramatic flair. The crowds that had gathered laughed at her, but she ignored them and lay there silently until addressed.

When I got around to her, she explained that her water had been leaking continually for over 3 days. She had no contractions but was haunted by a constant lower abdominal pain that had compelled her to come for help.

Honestly, the continually leaking water worried me, so I checked her out. Her chart indicated that she’s been here only once before. At that time, I couldn’t tell if she was carrying twins or a very large term baby. Either way, it/they were breech.

When I checked her this time, she was already 2-3 cm dilated with ruptured membranes. The tiny buttock presenting, made me think she was carrying twins. But if that were the case, one of the babies was dead. I could find only one heartbeat.

I was still trying to figure out what to do with her, when Biyana came in.

Biyana as many of you may recall was here a few weeks ago with a vesico-vaginal fistula at 5 months pregnant. At that time, I had tried to assess it but it was too painful, so I referred her to Wau. (Read her story here.)

But yesterday, when she came back, it wasn’t about her fistula; she was bleeding.

My heart started to sag with the strain.

When I examined her, some bleeding was visible, but she wasn’t in labor. I tried to do a speculum exam, but she hit the roof in pain. Calling for Tom, we decided she was having an inevitable premature birth, and decided to sedate her.

Once the drugs took effect, I was able to place the speculum with ease. What I saw though... took my breath away.

A pool of dark red blood obscured it at first, but then it moved! Five white fingers flexed and twitched in unison. I was looking at a hand!          -- Sh#*!

Both Tom and Sarah bent low to inspect it for themselves. Could it be true? Her baby’s hand had prolapsed!

Because of the pain she experienced with the digital and speculum exams, I worried how she’d handle a vaginal delivery in the first place. Now we had no choice; she was dilating.

We observed her for some time, but eventually induced her. Her husband kept insisting there was no money to take her to Wau, and that it would be better to make the child come out.

However, the oxytocin did nothing but cause her uterus to form a tight, painless ball. I couldn’t do digital exams to monitor progress; she wouldn’t allow it. This went on for several confusing hours. 

In that time, Sarah caught Victoria’s baby. It was a fun birth. But I'll let her write about it on her blog. I'm sure she will soon.

Victoria and her little girl.

Adeng also progressed but not as quickly as her family wanted, so they opted to take her home. They promised to bring her back once it was time to deliver, then whisked her away.     --Sigh. I didn’t argue.

And Aboul... well Aboul slept the night at the clinic. We didn’t want her to go home, but we didn’t want to induce labor either. She needs a cesarean not induction. After loading her with antibiotics, she slept and promised to call her husband in the morning.

By 10 pm, we stopped trying to induce Biyana because it wasn’t working. Her baby was still doing famously --his little heart ticked like a drum-- but there were no signs that she was dilating. So we agreed to try again in the morning. 

Exhausted, both Sarah and I wrapped up the clinic. Aboul was sleeping, Biyana and her husband were well, and Adeng had gone home to labor. Victoria was recovering with her baby girl at her breast. So, we bid them all good night and went to sleep.

By sun up, Victoria was discharged, Aboul was rested, and Biyana reported no more pain or contractions.

But what would be our plan of attack?

I consulted with Tom, and we decided on watchful waiting. I’d focus on the prenatals accumulating out front, and deal with Aboul and Biyana later in the day.

By noon, I had finished with the prenatals, and I decided to try and induce Biyana again. But after several hours of oxytocin, nothing happened. The problem was, I couldn’t tell if she was dilating.

What happens if she cannot dilate? What then?

Finally, I bit the bullet and did a vaginal exam. It caused her tremendous pain, but I was finally able to get some answers.

She was still only 2-3 cm (no progress despite induction). Also, her baby’s entire right arm was prolapsed into her vaginal vault.

Yes. You read that right. A prolapsed arm that wiggled.

Despite my better judgment, I tried to replace the arm back through the cervix, but Biyana screamed and writhed in pain. Unable to watch her suffer anymore, I stopped.

What more could be done? We were out of options, so I informed her husband she HAD to go to Wau.

The baby was transverse. The cervix was not dilating. She needed surgery. She also needed her fistula fixed. Only after I explained the situation in detail for the third time, did he move. I repeated over and over again. “Your wife will die without surgery.” “She needs a cesarean or she will not live.” “Take her to Wau if you want her to live.”

Could I have been more clear?

I don’t mean to insinuate that he was calloused or dull. He is a husband that cares and is moved with love and compassion. He wanted to take her to Wau, but he kept insisting there was no money.

The look he gave me as he asked me to try again, will haunt me for the rest of my life. 

I can no longer muster hope.        

Finally accepting to go to Wau, her husband asked me to write an official referral for the doctors there. But as I was writing up the referral, my translator came running to get me.

“Come quick. The hand is coming out of her vagina,” he sputtered. 
“I know,” I spoke slowly, “There is nothing I can do. Tell them to go to Wau.”
“No. You don’t understand, Akuac, the HAND is out!” he insisted.
Frustrated and spent, I raised my voice, “No,” I hissed, “You are not listening. I have told them, there is nothing I can do. The baby is not coming out. It is only the hand. Go tell them they must find a way to get to Wau quickly.”

Turning back to the paperwork, I knew I had spoken too harsh, and I instantly felt bad. What did they want of me? Can I turn this child? Can I make him come out? Can I heal her wounds? Can I stop this pain?

I’m helpless -- heartbroken and helpless.

I have no ambulance (the government of Southern Sudan won’t give us the clearance papers). But even if I did, there is NO fuel in Sudan. Something has interrupted the fuel imports and the gas stations are empty.

How Biyana’s husband is going to find a bus, afford the exorbitant price for the seats..... and then afford the TWO surgeries she’ll need, I cannot begin to imagine. 

I knew in coming here, I’d see such things. I knew I’d experience these kinds of obstacles, but I didn’t know it would hurt so much. Overwhelmed and hopeless, I’m ready to run away. I’m ready to hide.

Lord, hide me in the shadow of Your wings! Hide me Lord from the pain and suffering I see. My heart can’t take any more.

My heart is not used to such suffering and pain. It’s leaking dry. Soon it will be a hollow heart-shaped shadow. What will I have to offer anyone then?

Oh, Lord. I’m tired. Please help me hope again. Please do a miracle for Biyana.

Pray.  Pray as He leads you.               --I’m out of words.

P.S. Some of you might be wondering... but what of Aboul. Well, she is waiting for her husband to come. She’s stable. Her water is still ruptured, but so far no infection has set in, and her labor has still not begun. We are waiting. She, too, needs to go to Wau. She needs a cesarean. Pray she can get it.

And what about Adeng?  Well, I suspect her family had her deliver at home. She never returned.

Heart-shaped perfection.

A heart-shaped face perched atop elegant shoulders, drooped slightly in despair as she explained; there was bleeding. It started at noon. It was getting worse.

At first I didn’t know what to think, but then I saw it --Dark red stains and clots. Oddly, there were no contractions.

Painless vaginal bleeding tends to indicate placenta previa (when the placenta grows over the cervix causing bleeding during labor). There was just one thing... she wasn’t term.

Her brown taut belly only measured 25 cms, and the child palpated to be about 6 months along.

Questions raced through my head.   
--Previa? Stillbirth? Preterm? SGA baby? What?

Checking for heart tones, I was surprised by a steady thuk-thuk-thuk-thuk that echoed throughout the room.       
--Her child was alive and remarkably NOT in distress, but for how long?

Her name was Abuk.

Studying her chart, I learned that she had come to see me once several months ago, and then again came last month to be treated for STDs. She said the medicine she got hadn’t helped. She still had many of the symptoms.

While calling for a consult, I set up for a speculum exam. I needed to know exactly what I was dealing with. I would be able to see the if the placenta was in the way... or if she was even in labor.

Dennis arrived quickly, and we stopped to discuss her case at length.

Even though her LMP put her at 22 weeks GA (or 5 months), she was obviously more; her fundal height clearly indicated more like 6 months. But if she was having a simple preterm birth, why was there so much blood loss? Why the clots?

This had to be something more. Right?

Since night had already fallen, we could no longer safely refer them to Wau. And even if we could, what would Wau do for them?     --Nothing. Not at 6 months.

Dennis went to talk to her husband while I did the speculum exam.

Once past the obvious bleeding, I was able to clearly see her cervix. She was almost completely effaced and was well passed 4 cm dilated. Tinged blue, the bag of waters glistened under the flashlight’s yellow glare.         --She’d deliver soon.

Abuk listened carefully as I outlined the options:
“One, you could go to Wau right now, since your contractions were so far apart, but getting there at night is tricky. Two, we could admit you to our clinic, make you comfortable, and wait for your child to be born. Or three, we could induce you... but induction is painful... and well, it is hard on the child, too.
Piercing black eyes flashed from me to the floor, to her hands, to her blood, as I spoke.

“Think about it, talk to your husband, and I’ll be back in a few min...” I barely had the words out when she interrupted: “Just help me stay alive.” Only then did it occur to me she thought she was dying.

“Abuk, I promise you. You are doing fine. No matter which choice you make, you will not die. Please, don’t be worried.”
Nodding at my words, she sat there studying my face. Could I be trusted?

“Please... talk to your husband. Decide together what is best.”
“No. I don’t need to. Why wait? My child is going to die no matter what. I want to be induced.”

As the truth of her logic settled in my heart, my tongue went numb. I had no more words.

“Still, think about it a bit more.”
Nodding, she curled in a small ball on the bed and rested, and I called for her husband to join her.

“Abuk, can I invite my friend to come pray with you?” I asked.
“Yes. I would like that.” Her face softening a bit at the thought.

Suzy, my director and prayer warrior, came to pray with them while I discussed her case with the rest of the staff. We all agreed. There was no stopping this birth. There were no drugs we could give. It was inevitable.

I would induce.

While preparing the room, my heart sagged with questions.

Why the hurry? Why not let the child come naturally? Was I doing more harm than good? Was I killing this child? Was I saving her life?

Understanding never fully came, but her baby did.

An hour later, a beautiful little girl was born. She had the same heart-shaped face of her mother. Beautiful.

Weighing just 900 grams, she never tried to breathe.

After examining her perfection, I wrapped her in a blanket and asked the father: “Do you want to hold her?” He didn’t hear at first, so I asked again.

I had to ask several times before he lifted his head from the table. The day’s events were too much for him; they weighed him low.

“Why don’t you hold her. She is so beautiful,” I said gesturing towards the beauty.
“Yes. I want to hold her,” he said softly, and took her in his arms.

He unwrapped her, once or twice, for a closer look, and then tenderly balanced her tiny frame on his knees.

“Will you name her?”
“Yes. She will be named after my mother,” he said hesitantly, then later added, “No. I can’t name her that. I can’t name her now that she’s dead...”

Abuk returned to a fetal position on the bed -- too tired to cry.

Six months of hopes. Wrapped in a blanket. Breathless but perfect.

Suzy and Sabet came together afterward, and we all prayed again before taking them home. It was a sad birth, but one showered in prayers.

Please continue to pray for them as the Lord leads. Thanks.

A Puzzle.

Athong on her first prenatal.

This week brought many new and strange cases to my door. Cases ranging from possible placental abruptio, to ectopic pregnancy, to placenta previa. None of which, could I properly diagnose (no ultrasound machine), so I quickly referred them to Wau.

Why my brain goes to all these worst-case scenarios eludes me. I must be tired. Perhaps, they were just having normal bleeding.... but when is bleeding and sharp pain ever normal in pregnancy? My point.

Plus, I had to tell, not one but three women, that their babies had died in utero. Definitely low points this week. 

But of all the women, who lay on my prenatal bed, one stands out. Her name is Athong.

(For the midwifery minded out there, she is a G6 P3 L0 A2. Not good.)

Her first baby died during delivery after a 3 hour shoulder dystocia. (Yes. Read that again. 3 hours.) Her second baby was born prematurely (at 6 months), and died a few hours after the birth. Her third baby also died within hours of his premature birth (also at 6 months). The fourth baby miscarried at 3 months. The fifth miscarried at 2 months.

She was now on my bed telling me she was 5 months pregnant... or maybe less. There was no baby bump and no fetal heart tones, so I ordered a pregnancy test. Honestly, I was leaning toward her NOT even being pregnant.

When it came back positive, I got hopeful.

What her history screamed to me was an incompetent cervix due to her traumatic first delivery. But that would only explain the two premature births, not the two miscarriages. Sigh.

Differential diagnosis made me think syphilis or some other kind of STD; but perhaps she had a Rh-negative blood type and became sensitized somehow. Wouldn’t that explain her history better?

She was a puzzle-- a sad puzzle where each piece brought tears and dashed hopes.

Fortunately, our lab can test for blood typing and syphilis, so I sent her for an evaluation. Her blood was Rh-positive and she didn’t have syphilis. (Both results pointed toward incompetent cervix.)

I asked if I could do a speculum exam to see if her cervix had any noticeable tearing or scarring. She agreed happily, saying, “Whatever you need! I will live here at the clinic if you tell me to, so long as this baby lives!” We laughed jovially. There was hope in her voice.

During the exam, I didn’t see any tears, but I did see extensive signs of STDs, which explained the last two miscarriages.

What that means is, if she is really 3 months pregnant now, then there’s time to do a cervical cerclage to help her maintain this pregnancy. Whoohooo!

(For those who don’t know, cerclage is when you sow the cervix closed to reinforce the pregnancy, until it’s term. The sutures are removed in the third trimester, so labor can progress naturally.)

I don’t know how to do this procedure, but I’m told Dr. Tom does. All we have to do is treat her STDs, make sure the pregnancy is viable, stitch her closed, then watch her like a hawk.

When I explained this possibility to her, she jokingly promised: “If you help me have this baby, and it’s a girl, I will name her Akuac! And if it’s a boy, I’ll still name him Akuac!”

We laughed heartily at the idea of a boy walking around named after a female cow, but I’m pretty sure she’s serious. Ha!

I warned her that I was not guaranteeing her anything. I was only promising to do everything possible to help, and pray like mad!

Will you join me? 

May this baby be the one that lives!

STDs and Exhaustion!

This week I have done 84 prenatals. That makes for one exhausted midwife! Of those 84, half were new patients. Where are all these women coming from? Don’t get me wrong, I love it, but I’m not sure I can keep this up much longer. I try to give them my best but by the end of a long day, my brain twitches.

Plus, a large portion of these women have raging STDs. It’s great they are getting treatment, but come on! Why are so many of them infected? I asked my translator what he thought and he just shrugged. So, I pushed him a bit.

-- “When these young women marry older men, are they faithful?” I asked.
-- “Some go to any man that comes,” he explained, “but not all.”
-- “So is it the men? Are they unfaithful?” I asked, already knowing the answer.
-- “Yes. The men have sex with many many.” he explained.
I continued to pester. “But if they have ten wives, are they still sleeping with prostitutes as well?”
He just nodded uncomfortably.
-- “But why?” I badgered. I wanted him to say it out loud.
-- “Because they can,” he admitted, “that is the way of things here.”

Frustrated by constantly cleaning up after these unfaithful men, I have to admit that my translator is right. Socially here, it is understood that every man will stray. Monogamy is laughable to them. So what if they pick up a disease and cause their wife infertility and pain. That’s not their problem. If she cannot produce a child, he’ll just leave her in squalor and marry some new young thing.

One of those new young things was on my prenatal bed this week. She was two months pregnant and suffering from a long history of venereal symptoms. She was wife number five. Her last pregnancy ended in a miscarriage at 3 months which was most likely due to this infection.

Investigating further, she explained that three of the other wives were infertile. Even after years of marriage, they have never carried a child to term. So, I explained to her the role STDs play in infertility and miscarriage. Surprised but happy to learn this lesson early, she promised to take her medicines carefully and encourage the others to come for treatment as well.

This man, no doubt desperate for children, married five times. Did he know he was the problem? Probably not. Will he come for treatment? I don’t know. Will he allow his other wives to come? I hope so. I hope he gets a clue before it’s too late.

Sigh.

You probably didn’t think this post would entail me ranting and raving on the rate of STDs among the Sudanese. Ha! But there you have it. That is what you get from this exhausted midwife. Rants!

Pray for me to find socially acceptable ways to teach these families about STD prevention. I think some of the women will listen, but what about the men? There seems to be some kind of stigma; some men equate STDs with AIDS. They are ignorant that a few drugs can mean the difference between healthy children and pain free sex!

The good thing about all of this is... my translator gets it. I can safely say at least one Dinka man has learned this lesson well. Now for the rest of them!

STD Free zone?

For the last two weeks I’ve been doing a health teaching before prentals on sexually transmitted diseases. On the first day, I discussed it beforehand with my translator to see if I had to be culturally sensitive about any of the issues.

When I told him I was going to teach on STDs he cocked his head to one side and said, “But… there are no STDs in Sudan.” Dead silence.

Then it was my turn to be confused. I too cocked my head to one side and said, “Huh? Of course there are STDs. People have sex here don’t they?”

He shrugged as if to say I was wasting my time but agreed to translate for me all the same. So I forged ahead and taught them the signs and symptoms of the most common STDs, as well as the consequences of them.

Funny thing but over the last two weeks I’ve had a half dozen women tell me they have those symptoms… some have had them for years. They’ve been treated and have even brought their husbands in as well!

However, I’m pretty sure my translator no longer thinks Sudan is STD free zone.